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HomeMy WebLinkAboutBLDP& G-23-002283 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 6, CITY YARMOUTH MA DATE 10/27/22 PERMIT# BLDP-23-002283 ' JOBSITE ADDRESS 5 RHINE RD OWNER'S NAME MCKENNA PAUL A P OWNER ADDRESS 5 RHINE RD YARMOUTH PORT,MA 02675-2464 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES ID NO❑ FIXTURFS 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 WATER PIPING OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Stephen Winslow LICENSE 1Q298 I SIGNATURE MP © JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections@efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i(Iff g4 CITY YARMOUTH MA DATE 10/20/22 PERMIT# �-� 2z 5'3 JOBSITE ADDRESS 5 RHINE ROAD OWNER'S NAME ANNE MCKENNA P OWNER ADDRESS SAME ! TEL 781-690-7334 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL 0 PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:LI PLANS SUBMITTED: YES® NOEl FIXTURES Z FLOOR—► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB . j I I CROSS CONNECTION DEVICEINK 11111 1111111 NIB MN IIIII INN NMI MB INN All NMI Iliall INN NMI DEDICATED SPECIAL WASTE SYSTEM ' G DEDICATED GAS/OIUSAND SYSTEM initintimernerintimmirmaraffamtimmorinor1111111111111 DEDICATED GREASE SYSTEM 111111,. 11111111 MI MN MI 11111111111111 MK MI NMI MINI DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM } i DISHWASHER INN MINI INN MB MR IIIII MN INK INS INK NE'air MB NMI MK .---------_.. _-- DRINKING FOUNTAIN FOOD DISPOSER moor j11111111111111111111111111111111111111111 11111111111111111111111111.1111111110111 FLOOR/AREA DRAIN IIIIIIIIIIIIIIIIIIIII MIIIIIIIII NM NIB 01.111111111 II.11111111011111111111 MI INTERCEPTOR INTERIOR 1__ [MINWSIMI INIFIEWPOIEW =WM= KITCHEN SINK LAVATORY 1 ROOF DRAIN I� i � INK am NM SHOWER STALL MIIIIIIIIIIr IMF INF ,Ii SERVICE/MOP SINK sir TOILET � � --__ NM NM 11110111111111 lin NM NM MN URINAL .I I 1 ' _ . .. Wi WASHING MACHINE CONNECTION i m WATER HEATER ALL TYPES Nan.XIII MR Ilan Ina WATER PIPING IIIIFIIIFIIINIIIMIIFIIIWJIIIIIIIIIIIIIIIIIKMIIIIIIIIIIIIIIIIIIFIIIIIIIIFIIIIIKIIIIIIIIIIII OTHER __..., _ i i r `t _—MN MR .._ 1.1111 III III MOM MO IMMIMIIJINIIIMMINIIIIIIIIMINFIMNIINIIIIIFIIIIIIFJIIIIIIFIIIIIIIIMIIFIIIIIFIIIIIIIIIIIIIFIIMIIIIMIIIIIMIIIFIINIIFIIIIIIII I I` i _ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Li NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L' OTHER TYPE OF INDEMNITY El BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true a to the b t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co Ii wit II ertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW ... _ LICENSE# 12298 SIGNATURE MP JPLI CORPORATION[# 3281C PARTNERSHIP[I# I LLC®#� COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 J TEL 508-394-7778 J FAX 508-394-8256 CELL N/A j EMAIL INSPECTIONS acEFWINSLOW.COM MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE October 27,2022 PERMIT# BLDP-23-002283 ti JOBSITE ADDRESS 5 RHINE RD OWNER'S NAME MCKENNA PAUL A G OWNER ADDRESS 5 RHINE RD YARMOUTH PORT MA 02675-2464 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES ❑ NO❑ FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsr7ir.efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4.=>�c� :�t l=? CITY YARMOUTH 2'S— Z,2 V3 MA DATE 10/20122 PERMIT# G JOBSITE ADDRESS 5 RHINE ROAD OWNER'S NAME ANNE MCKENNA OWNER ADDRESS SAME TE 781-690-7334 FAX ----1_ TYPE OR OCCUPANCY TYPE COMMERCIAL, EDUCATIONAL RESIDENTIAL Lti CLEARLY NEW:,„ RENOVATION:El REPLACEMENT:Ej PLANS SUBMITTED: YES 0 NO APPLIANCES 1 FLOORS—) BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER .. ...: ._. __OM 11.11110111111. CONVERSION BURNER COOK STOVE fi DIRECT VENT HEATER DRYER . AMC FIREPLACE FRYOLATOR FURNACE - _ GENERATOR GRILLE �- 11111111 11.111$111111 111111.111.1 ern OK OM MI INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER [ I ROOF TOP UNIT TESTin [ , ,_ , , UNIT HEATERmumialui O:: . .,. . UNVENTED ROOM HEATER WATER HEATER ummenisami ` snspalr OTHER_ .. f . INSURANCE COVERAGE I have a curren t liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Lj NO LI I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Li BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurat to the b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc as Pirtine Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 7R^� provision of the PLUMBER-GASFITTER NAME STEPHEN WINSLOW Y LICENSE# 12298 I SIGNATURE MP MGF Li JP U JGF LI LPGI 0 CORPORATION 0# 3281C PARTNERSHIP # LLC Litt .._µ. . COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS L,8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE i MZIP 02664 ITEL 508-394-7778 FAX 508-394-8256 CELL N/AEMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents x= t t Office of Investigations ABM Lafayette City Center _' : 2Avenue de Lafayette,Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: E.F.WINSLOW PLUMBING & HEATING CO, INC. Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Business Type(required): 1.WI I am a employer with 99 employees (full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sale;(incl. real estate,auto,etc.) employees working for me ..,any capacity. [No workers' comp. insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. #1964A Expiration Date:01/01/2023 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under§25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' 7 the ins and penalties of perjury that the information provided above is true and correct. Signature: Date: 12/01/2021 Phone#: 508-394-7778 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 1.0Board of Health 2.❑Building Department 3.0 City/Town Clerk 4.❑Licensing Board 5.1:Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia